Incorporating Decentralized Healthcare Outlets Into a Value Based Care Model

How shall we attempt to manage chronic disease in the era of the “Doc in a Box?”

There is a growing and robust consumer-oriented outpatient marketplace.  Venues for care now include urgent cares, primary care variants, and free-standing ER’s, amongst others. Patient demand for convenience and access is driving the growth.  This decentralization of access is disruptive to the age old general practioner-specialist care team paradigm.  As a result, patients accessing these decentralized points of care are often not evaluated in a continuum that can address chronic disease and provide more preventative care solutions.  In a value based healthcare model, this is problematic.


Patients often seek care at these venues for specific acute episodes of illness or injury.  Typically, the patient’s episodic need is addressed and they are sent home; until the need for the next episode of care presents itself.  Such acute episodic care venues are likely here to stay due to patient demand.  It is projected that by year 2020, more patients will receive their “primary care” at these outlets rather than more traditional office based visits.


It is well documented that ER visits are not only costly, but they also typically fall short of providing comprehensive care for health issues outside of the patient’s chief complaint.  In a system of care that is going to reward physicians and hospitals based on metrics such as readmissions and other clinical indicators, we are going to need a solution to connect chronic disease management to convenient care outlets.  Patients with chronic diseases such as hypertension, diabetes, COPD, and cardiovascular disease that receive care at these venues present a new challenge for how to incorporate these “doc in a box” models into the healthcare value chain.


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Participant comments on Incorporating Decentralized Healthcare Outlets Into a Value Based Care Model

  1. Bruce,

    This is a great point. I recall seeing the proliferation occurring in large cities like Dallas, San Francisco and Boston a few years ago. As you alluded to patient demand has only driven the growth. As healthcare continues to transition into value-based care, “Doc in the Box” outfits will have to forge business partnerships/affiliations with larger formal systems. I believe that as patient care increasingly is provided under risk-based contracts, “Doc in the Box” variants that are not part of larger provider networks will lose patients. Partnerships between these variants and larger systems are symbiotic; health systems want to extend their net towards accessing these patients (pop health) and “Doc in the box” variants wanting to be included in local provider networks. The next key piece after forming these affiliations/partnerships is to integrate and exchange of electronic patient data.

    1. Thanks Neil!

  2. This is the most glaring weakness of Value Based Care – Patient Attribution. How do we decide which physician or which hospital is responsible for specific patients? And for how much of their costs and care over the course of a year? Many of the initial ACO’s struggled with this concept. They could manage costs well within their system, but patients had the ability to go outside of the system and then there was no cost containment. Right now patients are attributed to physicians for the purpose of Value Based Purchasing and now MIPS and many of us don’t even realize it. Value based care requires closer contact with a PCP who can effectively manage a patients chronic problems, but patients don’t necessarily want that, they want the convenience of seeing whoever they want, when they want. We can’t give patients choice of who they want to see, and then make a specific physician responsible for that patient’s care and costs over the course of a year. I think CMS is hoping it all averages out, but I don’t think we have a solution to this problem yet.

  3. This question brings to my mind Beef and Chicken analogy. If one form of meat is more accessible or convenient to obtain, people are more likely to buy more of it for consumption. In contrast, beef and potatoes might be viewed as complementary if having more beef encourages people to buy more potatoes.
    As leaders of the organizations, I believe we should first plan our strategy based on our community needs – are we going to provide substitute services similar to these free standing facilities (redesign organizational care processes) or complementary services (integrate with urgent care/ free standing facilities). Next step would be to strategize around these selected services/ collaborations in alignment with our value based care, population health initiatives to better meet needs of our patient population.

  4. This appears to be a classic example of the market adjusting for what patients desire out of healthcare but is at odds with third party payers idea of value. Ad hoc episodes of care delivered efficiently and cost effectively appeal strongly to distinct classes of patients: younger, healthier (those without the burden of major chronic diseases), and those with the ability to pay for the service either out of pocket or through insurance. Unfortunately this paradigm is at odds with the concept of integrated care, and does not provide the longitudinal care many patients require, specifically the elderly or those with severe chronic disease. It also may alter the patient mix at hospitals and ED’s as these will see a disproportionate share of the unfunded or lightly funded patient that may not be able to pay for or access the acute care stand alone facility. Ultimately, the solution may require a merging of acute care stand alone facilities and larger hospital chains with integrated mechanisms to ensure patient navigation, compliance, and referral to specialists within network in order to safeguard patients from falling through the cracks.

  5. I have enjoyed this discussion. Perhaps related is that of a new service that has recently entered our community, Direct Primary Care. These patients pay a flat, monthly retainer fee for a full range of comprehensive primary services (routine care, regular check-ups, preventative care, and care coordination) increased access to a physician, quick appointment scheduling, and more thorough visits (Each MD has 600-1000 patients/physician rather than the typical 2000+). Each visit is then only $20. This is a contract, not insurance, and does not meet the ACA needs. Patients are still encouraged to get health insurance to cover larger expenses, catastrophic events, and services outside of primary care. Monthly fees are age based and max out at $120 for a family. I have to admit that I even thought about it in addition to my employer-provided, high-deductible health plan when I considered that one PCP visit for cost is $150 for a sick visit. It is especially good for a younger single person that could go on a high deductible plan and carry this for only $25-$35 per month. They claim that this is possible as a business model by eliminating the paperwork associated with insurance companies & government agencies. If interested, more info on this specific service in my community can be found at

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